A strain of linezolid-resistant MRSA was isolated from a patient with acute myeloid leukemia after hematopoietic stem cell transplantation in the third relapse. The MIC to linezolid of the MRSA isolate was 32μ g/ml. PCR amplification and DNA sequence analysis of domain V region of 23S rRNA demonstrated a G2576T mutation in the linezolid-resistant MRSA isolate. Pulsed-field gel electrophoresis, spa typing and antibiogram analysis showed the genetical similarity of the linezolid-resistant MRSA isolate to the linezolid-susceptible strain isolated from the patient before linezolid therapy. These results indicate that linezolid-resistant MRSA was induced under the selective pressure of prolonged linezolid therapy in the linezolid-susceptible MRSA isolate. Moreover, the growth of the linezolid-resistant MRSA isolate was slower than that of the linezolid-susceptible MRSA isolate, and incubation took at least 48 hours for the susceptibility test of a linezolid- resistant MRSA isolate. These results indicate that long term linezolid therapy should be avoided and the susceptibility test of linezolid should be carefully performed.

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A 58-year-old female presented with chief complaint of disturbance of consciousness. Plain computed tomography scan showed an extensive low density area in the left temporal lobe and right frontal lobe. Further investigation showed far advanced ascending colon cancer with paraaortic and supraclavicular lymph node swellings by CT scan. Colonoscopy revealed a type 2 tumor in the ascending colon that was poorly differentiated adenocarcinoma histopathologically. Under diagnosis of advanced ascending colon cancer with brain metastasis and Virchow's lymph nodes without liver and lung metastases, we performed stereotactic radiosurgery for brain metastases, and the nervous symptoms disappeared. Ileocecal resection was perfomed for prevention of bleeding and intestinal occlusion. Chemothrapy with mFOLFOX6 were perfomed on 26 postoperative day, but she died 62 days after admission (42 postoperative day) by the cause of aspiration pneumonitis. Simultaneous brain and Virchow's metastases from colon cancer is extremely rare, and few patients survive more than one year postoperatively even with modality therapy, but performance status improved in neurologic status byradiosuregery.

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A 57-year-old male with hepatitis B virus-related liver cirrhosis, who had undergone right lobectomy and radiofrequency ablation for hepatocellular carcinoma, was admitted to our department for the purpose of examination and treatment of melena. Esophagogastroduodenoscopy (EGD) on admission showed duodenal varices without active bleeding in the 2nd portion of duodenum. In addition, total colonoscopy, capsule endoscopy, and double-balloon endoscopy via the anal demonstrated massive dark-red clot in the ileum and colon, but not pointed out a source of bleeding. Thereafter, the angiography via superior mesenteric artery revealed large portal-systemic shunts around the duodenum and computed tomography during arteriography showed extravasation at the 2nd portion of duodenum. Urgent EGD enabled us to diagnose as ruptured duodenal varices and endoscopic variceal ligation (EVL) was successfully performed. However, two days later, he suffered from hemorrhagic shock because of rebleeding of duodenal varices and balloon-occluded retrograde transvenous obliteration (B-RTO) after second EVL finally led to complete hemostasis. We report this rare case of ruptured duodenal varices treated by combination therapy of EVL and B-RTO in a cirrhotic patient.

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A 60-year-level man was admitted to our hospital for further investigation of duodenal submucosal tumor which had ulceration on the top. Although endoscopic forceps biopsy revealed only normal duodenal mucosa, pathological examination by endoscopic ultrasonography-guided fine-needle aspiration showed tumor cell which had cord and ductal like structure. In immunostaining, tumor cells were positive for chromogranin A, synaptophysin and CD56. Partial duodenectomy was performed as a duodenal carcinoid tumor. 34 months after surgery, he is alive without recurrence.

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This is the case report of a 69-year-old female patient, who presented to a hospital due to melena as the chief complaint. A lower gastrointestinal endoscopy confirmed a 0IIc + IIa tumor found in the patient's lower rectum (Rb). On a biopsy, this patient was diagnosed with a squamous-cell carcinoma or an undifferentiated adenocarcinoma first. Upon the patient's strong request, a local excision of the rectum was performed as the medical treatment for this case. No duct-like structure was observed histologically in the surgical specimen, and the immunohistological detection did not confirm any mucoid secretion or endocrine granules. For these reasons, this patient was diagnosed with an undifferentiated carcinoma. Generally, undifferentiated carcinoma of the colon has a poor prognosis, thus early detection is desirable. However, there exist a number of unclear points in the initial picture of this carcinoma. This is to report our experience of this rare case, which is an example of undifferentiated carcinoma of the colorectal region.

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We report a case of neuroendocrine tumor of the ileum with liver metastases. A 50 year-old level woman was pointed out multiple liver tumors by the abdominal ultrasonography and admitted to our hospital. Histological diagnosis was neuroendocrine tumor G1 (WHO classification) on tumor biopsy of the liver. Multiple ileum tumors were found on endoscopic examination of the ileum using double balloon endoscopy and assessed as a primary lesion. Transcatheter arterial infusion chemotherapy using iodized oil (lipiodol) and degradable starch microspheres (Lip-TAI using DSM) was performed for the metastatic lesion of the liver, and tumor regression was observed. Long-acting somatostatin analogue (octreotide) was administered once a month as an additional therapy. Inhibition of the tumor proliferation in both primary and metastatic lesion was observed for about 2 years. Combination therapy with Lip-TAI using DSM and biotherapy with octreotide will be a promising therapy for unresectable neuroendocrine tumor with liver metastases.

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